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Original Article

Longitudinal Effects of Rapid Maxillary Expansion


A Retrospective Cephalometric Study

Daniela Gamba Gariba; Jose Fernando Castanha Henriquesb; Paulo Eduardo Guedes Carvalhoa; Simone Carinhena Gomesc
ABSTRACT Objective: To evaluate the long-term effects of rapid maxillary expansion (RME) via banded expanders in the sagittal and vertical facial planes. Materials and Methods: The sample consisted of 25 patients who had undergone RME (with either Haas-type or Hyrax hygienic expanders) followed by standard edgewise orthodontic therapy. This sample was compared with a group of 25 patients who had edgewise treatment only and with a control nontreatment group of 26 subjects, matched by age and gender with the patients of the other two groups. Lateral cephalograms were taken before treatment (T1), at the end of treatment (T2), and at 3 years posttreatment (T3), comprising a 5-year average time of observation. Results: RME treatment, in the long-term, did not inuence the sagittal position of the apical jaw bases or the facial vertical dimension. Conclusion: Unfavorable cephalometric changes resulting immediately after RME are temporary, and therefore concerns about using RME in patients with vertical growth patterns or an extremely convex facial prole are not substantiated. KEY WORDS: Cephalometrics; Rapid maxillary expansion; Long-term stability

INTRODUCTION Rapid maxillary expansion (RME) constitutes a routine clinical procedure in orthodontics, with its main purpose to normalize the constricted maxillary arch. Forces of large magnitude delivered during activation of an expansion screw1 open the intermaxillary suture,24 increasing the basal bone width2,4,5 and the dental arch perimeter.6 In addition to the desirable transverse alterations, RME produces perceptible changes in the sagittal and vertical facial planes. The literature clearly demonstrates that, immediately after expansion, there is downward maxillary displacement
Associate Professor, Department of Orthodontics, University of Sao Paulo City, Brazil. b Professor, Department of Orthodontics, Bauru Dental School, University of Sao Paulo, Brazil. c Graduate Student, Department of Orthodontics, University of Sao Paulo City, Brazil. Corresponding author: Dr Daniela Gamba Garib, University of Sao Paulo City, Department of Orthodontics, R. Rio Branco 19 18, Bauru, Sao Paulo 17040-480, Brazil (e-mail: dgarib boston@hotmail.com)
a

Accepted: March 2006. Submitted: November 2005. 2007 by The EH Angle Education and Research Foundation, Inc.
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and extrusion of the supporting teeth, leading to downward and backward mandibular rotation.2,4,715 The opening rotation of the mandible induces cephalometric changes, such as increases in inclination of the mandibular plane, in lower anterior facial height, and in facial convexity, in addition to evident bite opening in the anterior region. In this context, some orthodontists have advised against performing RME in patients with predominantly vertical growth patterns and convex facial proles16,17 to prevent worsening of the malocclusion. Other clinicians have recommended the simultaneous use of other appliances, such as high-pull chin caps,1820 occlusal plates,21 or expanders with acrylic occlusal coverage,8,2225 to minimize the undesirable anteroposterior and vertical effects of RME. Most cephalometric studies of RME performed to date are limited to short-term evaluations, which have revealed partial relapse of the vertical and sagittal effects following the retention period.4,12 These results led to uncertainties regarding the longitudinal behavior of these cephalometric changes. Do the undesirable sagittal and vertical effects of RME become negligible over time, or are they maintained, justifying professional care to prevent them? Few lateral cephalometDOI: 10.2319/121405-439

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443
Table 1. Description of Patient Samples by Age in years and Observation Periods Groups
a

ric investigations have been conducted longitudinally on RME,15,2628 and the majority of studies had no control group against which to make adequate comparisons.15,27,28 In light of these facts, this study was designed to evaluate the longitudinal cephalometric changes caused by RME followed by edgewise mechanics and to compare them to the changes caused by edgewise mechanics without previous expansion. Changes resulting from craniofacial growth and development were also compared with those of a control nontreatment group. MATERIALS AND METHODS All patients were selected retrospectively and consecutively. Three groups of subjects were analyzed. Group 1 (RME group) was composed of 25 white patients (11 male, 14 female) with a mean age of 13.5 years (varying from 11 to 17.3 years) at treatment onset who presented with either Angle Class I (I) or Class II, division 1 (II/1), malocclusions (14 and 11 patients, respectively) and posterior crossbite. Approval was received for the use of human subjects in this study by the human subjects committee of the authors university. Group 1 underwent RME with either tooth-tissue supported (Haas type) or tooth-supported (Hyrax or Hygienic) expanders, followed by standard edgewise therapy. The expanders were activated 5 to 9 mm over a period of approximately 2 weeks until the posterior crossbite was overcorrected. After completion of the active expansion phase, the expander was kept as a retainer for 3 months. During edgewise therapy, 6 patients had four rst premolar extractions and 19 patients were treated with no extractions. Lateral cephalograms taken before treatment (T1), after active orthodontic treatment (T2), and 3 years after treatment (T3) were used in this study, comprising a mean observation period of 5 years. Group 2 (edgewise group) consisted of 25 white patients (11 male, 14 female), with a mean age of 13.1 years (ranging from 10.6 to 18.7 years) at treatment onset, presenting with Class I or II/1 malocclusion (11 and 14 patients, respectively). The treatment of these patients did not involve RME and was limited to the use of edgewise xed appliances. Extraction of four rst premolars was performed in 9 of the 25 patients, and the remaining 16 were treated without extractions. Three lateral cephalograms were obtained for each patient at the same stages described for group 1. Group 3 (control group) comprised 26 white (13 male and 13 female) subjects who did not undergo orthodontic treatment and who were selected from the records of Bauru Growth Center29 and matched by age

T1

T2

T3 T1 1.9 2.2 2.0

T2 T2 3.3 3.0 3.3

T3 T1 5.2 5.2 5.3

T3

RME group 25 13.5 15.5 18.7 Edgewise group 25 13.1 15.5 18.5 Control group 26 13.5 15.5 18.7
a

RME indicates rapid maxillary expansion.

to the patients in groups 1 and 2. Three lateral cephalograms of each individual were traced, obtained at ages 13, 15, and 18 years, corresponding to the mean ages at each treatment stage in the other groups (Table 1). Although the majority of this sample had normal occlusion, subjects with Class I or II/1 malocclusion were also included. Anatomic tracings and location of dentoskeletal landmarks were manually conducted by a single investigator for all three groups and then digitized (Numonics AccuGrid XNT, model A30TL.F, Numonics Corporation, Montgomeryville, Penn). These data were then stored on a 166 Pentium II computer and analyzed with Dentofacial Planner 7.02 Plus (Dentofacial Software Inc, Toronto, Ontario, Canada). This software corrected the magnication factor (6% to 9%) of the radiographic images and calculated the angular and linear cephalometric variables employed in this study (Figures 1 and 2). Statistical Analyses Descriptive statistics (means and standard deviations) were obtained for each cephalometric measurement at T1, T2, and T3 as well as for the changes between stages (T1 to T2, T2 to T3, T1 to T3). Analysis of variance (ANOVA) and Tukey test were used to identify intergroup differences regarding both initial values and changes over time (P .05). Eighteen radiographs were randomly selected, retraced, redigitalized, and remeasured by the same examiner after a 30-day interval. Casual and systematic errors were calculated comparing the rst and second measurements with Dahlbergs formula and dependent t-test, respectively, at a signicance level of 5%. Only one variable analyzed (SN.PP) had a statistically signicant systematic error (mean 0.3 ), and no variable showed an error greater than 0.5 or 0.5 mm. RESULTS A comparison of anatomic form at baseline (Table 2) revealed that the three groups had similar characteristics for 11 of the 15 cephalometric measures analyzed. Group 2 showed greater ANB angle than group 3 and greater overjet than groups 1 and 3. Other signicant differences included greater FMA angle and
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Figure 1. Cephalometric variables for sagittal and vertical evaluation. 1 indicates SNA angle; 2, SNB angle; 3, ANB angle; 4, NAP angle, skeletal prole convexity (Downs); 5, overjet; 6, SN.PP; 7, SN.GoGn; And 8, FMA.

Figure 2. Linear cephalometric variables for vertical evaluation. 9 indicates upper anterior facial height (UAFH); 10, lower anterior facial height (LAFH); 11, total anterior facial height (TAFH); 12, upper posterior facial height (UPFH); 13, total posterior facial height (TPFH); 14, U6-PP; and 15, overbite.

Table 2. Comparison of Anatomic Forms at Baselinea RME Group (n Variables Sagittal SNA ( ) SNB ( ) ANB ( ) NAP ( ) Overjet (mm) Vertical SN.PP ( ) SN.GoGn ( ) FMA ( ) UAFH (mm) LAFH (mm) TAFH (mm) UPFH (mm) TPFH (mm) U6-PP (mm) Overbite (mm)
a

25) SD 3.6 3.7 2.1 5.0 2.2 3.0 6.0 4.6 3.5 4.2 6.3 2.7 6.1 2.3 1.7

Edgewise Group (n Mean 82.0 77.5 4.5 7.7 5.9 7.8 34.7 26.9 48.0 62.2 110.3 38.6 68.2 21.9 2.4

25) SD 2.9 2.8 2.3 6.1 2.7 3.4 5.8 5.5 3.6 5.4 6.3 3.1 6.2 2.6 2.3

Control Group (n Mean 81.1 78.0 3.1 4.5 2.7 8.9 32.1 24.4 49.7 60.3 110.0 39.0 70.4 21.1 2.9

26) SD 2.7 2.8 1.7 4.9 0.7 3.2 4.6 4.1 2.7 4.2 5.1 2.8 4.2 2.0 1.2 ANOVA NS NS * NS * NS NS * NS NS NS NS NS NS *
C; BC B; BC

Mean 81.8 78.5 3.3 5.4 3.7 7.9 34.6 28.1 47.8 63.2 111.0 38.5 69.4 22.0 1.5

BC B

B C

C B

BC

BC

NS indicates not signicant; *P


C).

.05; Tukey test result: different letters indicate signicant differences between groups (B

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CEPHALOMETRIC LONGITUDINAL EFFECTS OF RME Table 3. Comparison of Treatment Changes (T1 RME Group (n Variables Sagittal SNA ( ) SNB ( ) ANB ( ) NAP ( ) Overjet (mm) Vertical SN.PP ( ) SN.GoGn ( ) FMA ( ) UAFH (mm) LAFH (mm) TAFH (mm) UPFH (mm) TPFH (mm) U6-PP (mm) Overbite (mm)
a

445

T2) Between Study Groupsa Edgewise Group (n Mean 1.1 0.1 1.3 3.4 3.5 0.6 0.3 0.4 2.2 3.0 5.3 1.4 3.8 1.5 0.8
A B B B

25) SD 2.2 1.4 1.2 2.9 1.5 1.7 1.7 1.7 1.9 1.6 3.1 1.5 2.2 1.4 1.5

25) SD 1.3 1.0 1.2 2.5 2.5 1.1 1.6 1.9 2.1 2.5 4.2 1.4 2.6 1.7 2.3

Control Group (n Mean 0.2 0.5 0.1 0.8 0.1 0.0 0.4 0.6 1.4 2.7 4.1 1.1 3.3 1.6 0.3
B A A A

26) SD 0.8 1.0 0.6 1.4 0.5 1.1 1.3 1.1 1.4 2.1 3.3 1.6 2.6 1.3 0.8 ANOVA * NS * * * NS NS NS NS NS NS NS NS NS NS
B; AB A; AB

Mean 0.0 0.1 0.1 0.5 0.9 0.7 0.0 0.3 1.4 2.0 3.4 0.6 2.4 1.3 0.0
AB A A A

NS indicates not signicant; *P


B).

.05; Tukey test result: different letters indicate signicant differences between groups (A

smaller overbite in group 1 compared to group 3. The number of patients with high mandibular angle (FMA angle greater than 30 ) in groups 1, 2, and 3 were 10, 7, and 4, respectively. During the treatment period (T1 to T2), there were no statistical differences between the groups regarding vertical changes (Table 3). Only facial convexity (ANB and NAP) showed a larger reduction in group 2 in comparison with the other two groups, which was the result of a decrease in the SNA angle in that group. Posttreatment changes (T2 to T3) are detailed in Table 4. There were no differences between groups during this period. Considering the whole observation period (T1 to T3), the majority of measurements that expressed facial vertical dimensions and growth patterns showed similar changes in all groups (Table 5). Between-group differences were restricted to sagittal features, with the edgewise group (group 2) displaying a signicantly larger decrease in both facial convexity and SNA angle compared with the RME (group 1) and control groups (group 3). DISCUSSION Precise evaluation of the longitudinal cephalometric effects of RME, which was the primary goal of this study, required identication of alterations related to craniofacial growth and orthodontic mechanics performed after RME in the study sample. In this way, a group of patients who underwent RME before mechanical treatment with xed appliances was compared to a sample of patients whose corrective ortho-

dontic treatment did not include RME. A control group of untreated subjects was also used to identify confounding factors such as the expression of craniofacial growth and development during the study period. Sagittal Changes Considering the changes in SNA angle, it seems evident that the maxilla in group 1 behaved similar to that of the control group throughout the study period (Tables 3 to 5). Group 2 was treated with edgewise mechanics only and was signicantly different from the other groups. In groups 1 and 3, the maxillary sagittal position remained unchanged in relation to the cranial base, considering the slight changes in SNA angle, whereas group 2 revealed maxillary retrusion during the treatment period (T1 to T2), probably a result of backward displacement of point A secondary to tooth extractions (Table 3). Analysis of the initial measurements in Table 2 reveals that group 2 presented higher values for ANB angle and overjet. Thus, in this group, dental compensation of the malocclusion required a larger amount of maxillary incisor retraction, which should be enough to cause remodeling of the maxillary anterior region and retrusion of point A. The contradictory data in the literature on the effects of RME on maxillary anteroposterior positioning, obtained from short-term observations, require critical analysis of longitudinal studies. Haas2 was the rst to mention the occurrence of anterior displacement of the maxilla after expansion. Thereafter, some cephalometric studies corroborated these results, 810,13,30 whereas other studies did not observe such displacement, instead noting variable sagittal behavior of the
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Table 4. Comparison of Posttreatment Changes (T2 to T3) Between Study Groupsa RME Group (n Variables Sagittal SNA ( ) SNB ( ) ANB ( ) NAP ( ) Overjet (mm) Vertical SN.PP ( ) SN.GoGn ( ) FMA ( ) UAFH (mm) LAFH (mm) TAFH (mm) UPFH (mm) TPFH (mm) U6-PP (mm) Overbite (mm)
a

GARIB, HENRIQUES, CARVALHO, GOMES

25) SD 1.4 1.3 1.1 2.4 0.7 1.3 1.4 2.0 1.3 1.9 2.8 1.5 2.7 1.2 1.0

Edgewise Group (n Mean 0.4 0.5 0 0.4 0.5 0.0 0.8 0.8 0.6 1.0 1.6 0.5 1.8 0.8 0.3

25) SD 1.0 0.7 0.7 1.5 0.7 1.4 1.3 1.5 2.0 2.0 3.5 1.5 3.0 1.1 1.2

Control Group (n Mean 0.1 0.4 0.2 0.7 0.2 0.2 1.0 0.8 0.3 0.9 1.2 0.6 1.9 0.5 0.1

26) SD 1.0 0.5 1.0 2.2 0.5 0.6 0.9 1.1 0.9 1.8 2.5 0.8 2.2 1.1 0.7 ANOVA NS NS NS NS * NS NS NS NS NS NS NS NS NS NS
B; AB A; AB

Mean 0.1 0.0 0.2 0.6 0.0 0.1 0.3 0.4 0.5 0.9 1.5 0.6 1.9 0.0 0.1

NS indicates not signicant; *P


B).

.05; Tukey test result: different letters indicate signicant differences between groups (A

Table 5. Comparison of Overall Changes (T1 to T3) Between Study Groupsa RME Group (n Variables Sagittal SNA ( ) SNB ( ) ANB ( ) NAP ( ) Overjet (mm) Vertical SN.PP ( ) SN.GoGn ( ) FMA ( ) UAFH (mm) LAFH (mm) TAFH (mm) UPFH (mm) TPFH (mm) U6-PP (mm) Overbite (mm)
a

25) SD 1.9 1.6 1.5 3.5 1.4 1.5 2.0 2.7 2.3 2.8 4.8 1.6 4.0 1.7 1.4

Edgewise Group (n Mean 0.7 0.6 1.3 3.8 3.0 0.6 0.5 0.4 2.8 4.0 6.9 1.9 5.6 2.3 0.5
A B B B

25) SD 1.4 1.2 1.4 2.9 2.4 1.5 2.0 2.3 2.5 3.3 5.1 2.0 3.7 1.8 1.7

Control Group (n Mean 0.3 0.9 0.3 1.5 0.3 0.2 1.4 1.4 1.7 3.6 5.3 1.7 5.2 2.1 0.4
B A A A

26) SD 1.1 1.2 0.8 2.1 0.4 1.1 1.5 1.6 1.8 3.0 4.7 2.1 3.8 1.5 1.0 ANOVAa * NS * * * * NS NS NS NS NS NS NS NS NS
B; AB A; AB

Mean 0.1 0.1 0.3 1.1 0.9 0.6 0.3 0.7 1.9 2.9 4.9 1.2 4.3 1.3 0.1
AB A A A

NS indicates not signicant; *P


B).

.05; Tukey test result: different letters indicate signicant differences between groups (A

maxilla that was clinically insignicant.4,12,14,15,23,31 The ndings of the present study revealed that RME did not yield any relevant long-term effect on the maxilla in the anteroposterior dimension. Other authors who applied longitudinal methodologies found similar results.15,2628 Interpretation of SNB angle changes showed no signicant differences among the three study groups regarding mandibular sagittal behavior (Tables 3 to 5). In both treated groups, as well as in the control group, the mandible presented forward displacement in relaAngle Orthodontist, Vol 77, No 3, 2007

tion to the cranial base. Thus, it can be concluded that neither RME nor corrective orthodontics inuenced anteroposterior mandibular growth. Chin retropositioning observed soon after RME owing to downward and backward mandibular rotation2,4,715 constitutes a temporary effect of RME. Studies that followed patients during the 3-month retention period after expansion had already demonstrated partial relapse of these alterations, with the cephalometric variables tending to return to their initial values.4,12 The current ndings conrm the results of previous longitudinal studies.26,27

CEPHALOMETRIC LONGITUDINAL EFFECTS OF RME

447 teeth,20 contributing to vertical increases. Even though cephalometric studies show partial relapse of such alterations during the retention period,4,12 the uncertainties of the longitudinal behavior of vertical facial dimensions could constitute a concern when performing RME in patients with a long face and/or an excessively retrognathic prole.16,17 Surprisingly, a comparison of the three study groups during the observation period did not demonstrate signicant differences between them regarding changes in facial growth pattern, facial height, maxillary rst molar extrusion, and overbite (Tables 3 to 5). These ndings corroborate the studies of Chang et al26 and Velasquez et al,27 which revealed that the vertical skel etal changes in patients treated with RME were not different after consideration of natural alterations resulting from individual facial growth. CONCLUSION Undesirable cephalometric effects observed immediately after RME with banded appliances were not signicant in the long term and thus do not contraindicate this procedure in patients with a vertical growth pattern or an extremely convex facial prole. ACKNOWLEDGMENT
The authors thank Dr Sheldon Peck, Harvard School of Dental Medicine, for his detailed review of this manuscript.

The variables that indicate the anteroposterior relationship between the maxilla and the mandible (ANB) and bony prole convexity (NAP) were reduced throughout the study period (T1 to T3) (Tables 3 to 5). This reduction in facial convexity was similar in the RME and the control groups, conrming that RME does not inuence the sagittal relationship between the apical jaw bases. Thus, the alterations that occur immediately after expansion and are frequently reported in the literature, such as increases in facial convexity and overjet,2,8,9,1214,32,33 should be considered ephemeral phenomena. These results do not provide a basis to contraindicate RME in patients with a convex prole based on the side effects observed soon after expansion. Only group 2 exhibited a statistically signicantly greater reduction in ANB and NAP angles compared to the other groups (Table 3). Since these angles are related to sagittal changes of the apical jaw bases, the greater reduction in facial convexity in group 2 is secondary to the retropositioning of point A previously discussed. Vertical Changes The palatal plane inclination (SN.PP angle) remained unchanged in the control group over the entire evaluation period (Table 5). Groups 1 and 2, which were treated, showed similar responses yet were statistically different from group 3, showing mild anteroinferior rotation of the palatal plane, with a mean of 0.6 . The literature presents varied responses of the palatal plane secondary to RME, from anteroinferior rotation to anterosuperior rotation.4,14 However, considering the lack of differences between groups 1 and 2, it does not seem reasonable to assign any longitudinal inuence in palatal plane inclination to the effects of RME. The changes observed for upper anterior and posterior facial heights (UAFH and UPFH) should also be emphasized, since there were no statistically signicant differences between the study groups (Tables 3 to 5). These data reveal that, even though RME causes vertical maxillary displacement, as demonstrated by several studies,2,4,9,11,14,15 this vertical alteration is not signicant in the long term. The results related to vertical facial changes in the RME group are of extreme clinical importance. It is known that RME increases lower anterior facial height (LAFH) and inclination of the mandibular plane and leads to anterior bite opening because of the downward maxillary displacement and extrusion of anchorage teeth.2,4,715 Furthermore, overcorrection of 2 to 3 mm during activation of the screw gives rise to occlusal interferences when the lingual cusps of maxillary teeth occlude against the buccal cusps of mandibular

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